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I think it improves every nail that I treat but it is hard to speculate why some become clear while others require ongoing treatment. Each patient I have found tolerates the laser differently. Some will say that they did not have any discomfort while another will say it got very hot. How they tolerate the treatment does not always correlate with how the nail responds down the track. I wish it would so I could give a better answer.

Hi - we have made a little "quiz" app for Android that has some very basic questions to determine if someone might have a need for a consult re nail fungus.

We are marketers, not podiatrists, and so this app is not very clinical - but it does spur some people to request a consult where we leave it up to you pros to help them further, if it seems appropriate to you and the patient.

The app is intended to generate some new leads/referrals and as we're testing the model we'd appreciate feedback. So far we've had good feedback from consumers, which is the target audience.

Oh and we have a few leads to give out, as we're starting to get a few coming in but have no one to send them to (they are 90% US and some outside USA).

We'd be happy to connect these prospects with members who might be looking for new patients.

I don't mean to hijack this thread so for more details and a current list of the leads pls see our thread here.

"Studies on fungal nail clippings
have demonstrated this to have a direct thermal killing
effect on fungal mycelia when treatment temperatures
exceed 50° centigrade [18]."

This idea is consistent with the wide variability of anecdotal outcomes reported in this thread. I have speculated within my own experience, (which was primarily with "severe" infection) that the dose limiting factor of intolerance to heating was likely reason for failure. Because of extremely poor outcomes (no cure) I rejected using this technology in my clinic and will not recommend to patients unless further evidence showing reasonable efficacy emerges.

In his review, Bristow pointed to the poor methodology used in majority of studies. I believe that we may not find good outcomes (high cure rates) unless we can overcome understanding the dose issue. Whilst anesthetizing toe would likely allow tolerance of a reliably heat destroying dose to dermatophytes it would likely have an unacceptable risk for host injury.

I have speculated that if the effect of onychomycosis causes separation of nail from nail bed there may be a sufficiently heat insulating air layer present to allow adequately destructive temperature within the nail plate without host injury. This might explain why Tim Foran had success in the examples he posted.

Another idea that I have not seen discussed is to investigate the effect a very short interval (ms) temperature exposure to in vitro onychomycosis. Because laser might be selectively "tuned" for photon energy absorption according to the pigmentation created within/around the dermatophyes it may be possible to heat those elements to very high temperature for very short time intervals with good effect without sufficient heat conduction to adjacent skin to cause injury to host. To achieve this might be largely a function of optimizing balance of pulse width and power output. Anyone aware if this approach has been considered or if it seems logically flawed?

I have speculated that if the effect of onychomycosis causes separation of nail from nail bed there may be a sufficiently heat insulating air layer present to allow adequately destructive temperature within the nail plate without host injury.

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I think you may find we discussed this many moons ago in this thread somewhere. We have data that shows debriding any onycolytic nail and applying the laser directly to the nail bed has very little success. Leaving the nail in place even in its lytic state seems to provide better outcomes.

I think you may find we discussed this many moons ago in this thread somewhere. We have data that shows debriding any onycolytic nail and applying the laser directly to the nail bed has very little success. Leaving the nail in place even in its lytic state seems to provide better outcomes.

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Hi Paul

Indeed we did, although I am unaware that this was reported by anyone but myself. I am canvassing opinion to see if anyone else has anything to add to that conversation at this stage given the apparent stagnation in well designed published studies in this area over the past year.

Indeed we did, although I am unaware that this was reported by anyone but myself. I am canvassing opinion to see if anyone else has anything to add to that conversation at this stage given the apparent stagnation in well designed published studies in this area over the past year.

We have all data collected, analyzed and reviewed - just needs writing up. You want the job?

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Haha ...... I would love to be able to responsibly say yes but if I did there would be yet another unfinished task relegated to the "en route to oblivion list" ....... But look forward to reading whoever does ... Good luck :drinks
cheers Martin

Haha ...... I would love to be able to responsibly say yes but if I did there would be yet another unfinished task relegated to the "en route to oblivion list" ....... But look forward to reading whoever does ... Good luck :drinks
cheers Martin

I have a quick question about the various nail lasers. I'm trying to understand if any of the wavelengths used in the various lasers could potentially increase the risk of cancer, in particular, skin cancer.

I have not seen this discussed anywhere. I'm wondering how you would answer a patient if they asked you this question?

When a product is approved by the FDA or given CE mark, has the laser company been required to undertake studies that demonstrate there is no cancer risk?

Laser treatment cannot be carried out on anyone who has had cancer of any type within a year, and not at all on anyone who has had skin cancer. If the patient has sunburn, then the treatment cannot be carried out until it has gone completely.

I don't think we have to worry about the laser causing cancer, as long as guidelines are followed.

I would be very interested if anyone has evidence to the contrary though!

BACKGROUND:
The role of the short-pulsed 1064-nm-Nd:YAG laser in treating onychomycosis has been the subject of controversial discussion ever since it received FDA approval in 2010. Research to date provides no valid conclusions supporting its use from an evidence-based perspective.
OBJECTIVE:
In this prospective randomized controlled pilot study, we analysed the effect of the short-pulsed 1064-nm-Nd:YAG laser on the rate of mycological remission and clinical improvement after excluding relevant confounders with regard to our previous studies.
PATIENTS AND METHODS:
Twenty patients with a total of 82 mycotic toenails were randomized to the treatment group (short-pulsed 1064-nm-Nd:YAG laser) or control group (no laser treatment). We conducted four laser treatments at 4- to 6-week intervals. In both groups, a local antimycotic agent was applied to the sole of the foot, the area between the toes and the skin directly surrounding the nails. The primary endpoint was complete remission of the onychomycosis after 12 months (fungal culture and histology); secondary endpoints included clinical improvement (Onychomycosis Severity Index, OSI) and the occurrence of pain or other adverse events.
RESULTS:
Mycological remission was not achieved in either study group. A comparison of both groups yielded no difference in the OSI score, both at the beginning of the trial (P = 0.9873) and after 12 months (P = 0.4317). In the treatment group, the OSI score worsened by a mean 2.0 points, and in the control group, by a mean 3.5 points. On a visual analogue scale (0 = 'no pain' to 10 = 'most intense pain'), pain in the treatment group was indicated at a mean score of five. Other adverse events were not reported.
CONCLUSIONS:
The short-pulsed 1064-nm-Nd:YAG laser shows no long-term efficacy as a monotherapy. Its role as an adjuvant therapy should be investigated in upcoming trials.

Until recently, pharmacologic molecules have been the only available treatments for onychomycosis. Laser treatments were introduced for recurrent or resistant cases or in patients in whom oral treatments are contra-indicated. Some devices were approved by the Food and Drug Administration (FDA). Neodymium yttrium aluminium garnet (Nd:YAG) is used for onychomycosis as a short-pulse or a long-pulse system. We aim to evaluate the efficacy of the short-pulse Nd:YAG in treating onychomycosis, its side effects, cure rates, and 12-month recurrence rates. Efficacy was evaluated based on a subjective measure of patient satisfaction on a scale from 1 to 10, and an objective measure based on the results of the mycologic cultures. Medical records of 30 patients were reviewed. Ages ranged from 22 to 85, with a mean of 44. Mycologic cure at 12 months was not achieved in 5 patients (16.67%) who had received laser treatment. None of these patients showed any signs of clinical improvement. Twenty patients (66.67%) were completely cured at 12 months, with corroborating negative mycologic cultures. The remaining five patients (16.67%) had discordance between their clinical cure status and their mycologic cultures. Side effects were reported by 7 patients out of 30 (33%): pain within 48 hours of the treatment session, burning sensation in the treated nail bed area. Our primary end point of negative mycologic cultures at 12 months was seen in 24 out of 30 (80%) of our patients. Similar culture cure rates have not been reported before, not even with systemic treatments with oral antifungals. However, few limitations should warrant us (False-negative results in fungal cultures; time limitation; sample size?). Still, we propose that this alternative should be offered for patients in whom antifungals are contraindicated or for patients previously treated, but not cured by oral antifungals, and in elderly and polymedicated patients.